Online Litigation Funding Application - Covered Bridge Capital, LLC

Personal Information

First Name:	MI:
Last Name:
SSN (optional):
Birth Date:
Email:
Primary Address:
City:
State:	Zip:
Primary Phone:
Fax:

Case Information

Date of Event:	Case Type:	State Your Case Is In:

Yes	No
		Has this case been settled?
		Have you taken prior funding on this case?
		Do you plan to apply with other funding sources?

Case Description:

Damages/Injuries Sustained:

Yes	No
		Do you have any other cases pending?

Attorney Info

First Name:
Last Name:
City:
State:
Phone:
Email:

Request Information

Please enter the amount of money you are requesting.

Authorization to Contact Attorney

I hereby request and authorize Covered Bridge Capital, LLC to contact my attorney to obtain relevant non-privileged case information for purposes of completing a funding request. Additionally, I authorize my attorney to share his/her candid opinion regarding my case.

Type your full name:
Today's date:

		Records Release Authorization

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